25776 APPLICANT TO•FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING A PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL r..
BUILDING PROJECT'IUEM'IF'IC-ATION NL`J
BUI DING ADDRESS: SANITARY NO. AP1PLICATIONSUBMITTALDATE
CO P ITN LOTH IL—I �2
O FPR PHONE: CONTRACTOR'S NAME: LIC NO: g.LF�•J
AlftN/C CONTROL N
'.:CIIITELT/F,NGINEIR: LIC NO. ADDRESS: ❑
CON'TA D ^ ` oNE BUILDING PERMIT INFO
QTY. ELECTRIC PERMITtrEEBLDG ELE PLUM MECHP[RMIT ISSUANCEHILDO` /JT�k—aH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
cmz Iherebyaffismthatlamlicenodunderpmvisionsof Chapter9(cammemingwiN A��] I-, I
J00 Section]OWlofDivisinn3mltheBusinessanJProfeeaionsCode,andmylicenseisin PANELS St 2-
fX W N full force and eRat.
FZ License Class Lic.N UPT02MAMPS w
WS
m?y Date Contra 201-1000 AMPS
ZOyZ ARCIIITECTSDECIARATION OVER 1000 AMPS SQ.ET.FLOOR AREA S/SQ.FT.
O Z O I understand my plans shall be used as public records. T
FNf'jCf
Y�...I
Licensed Professional Lf SIGNS
"CAL
'
d,4W'V OWNER-BUILDER DECLARATION SPECIA CI UV'/MISC.
OaF I hereby Whom that I um exempt firm the Contractor's License Luw for the
3�ma following renson.(Smtion]OJL5.Businessand Proftsaions Cod<:Myciry or county '1'1?hIP. LE INST.
�yJ Which reyuirtx a permit to cnnslmet,alter,improve,demolish,ar repair wy stmmure
taNaE prior In its ismunce.alsn reymres theapplicant for such permit to file a aigned statement POWER D f?S
1KyO0 that he is licensed pursuant orbs provisions of the Cantmctore License Law(Chapter
xo 9(rommencing with Section]OW)or Division Sof the Business end professions Code) SWIMMING VALUACf�
W_y or he iv exempt and the basis for the alleged exemption.Any violation of ���
I–ZQ Section 7031.5 by anyappliama forap.it subjau theapplicem toe civil Penalty of IITLEI'S-SWITCH -
�p•. neo
not mom than five hundred dollars($500),
Eo ❑ l,mownerofthe rc NO RESIDENTIAL ELE _SQ.IT.
p party.wmyGmployarwithwegesesthcirsolecompensation, STORIES TYPE?CONSTRUCTION
y3= willdothesimisCash: swcmmactotintendWr awdofarol apply
Business
and artyPrinWhiona Code:The Contractor's License Lew docs or apply lf an owner of
own eny wyces.pds or improver thereon, such work himulfnr through Ns _
employeesilding rI pr suchimprovemenuunot oroffered forsake. r. OCC GROUP RES.UNITS
however,the buildingorimpmvement it sold wiphinone yearofmmpletinn,the owner
builder will have the burden of proving that he did not build or improve for purpose of
oe
er
I,n ow of the propeny,nm exclusively cocontractorsecting with licensed contractors to QTY' PLUMBING PERMIT FEE ILOOD ZONE APN
test the project(Sm.704,1.Business and Professions Code:)The Convacmr's
icense Lawdeas mat apply toenownerofpropeny whobuildsorimproves thcreogand PERMIT ISSUANCE
ocnmrans forsuch projects with acnmreaor(s)licensed pursuant m the Contractors ALTER EEE SUMMARY
License Law. (EA)
❑ I am exempt under Sec. ,B @ P C for this reason BACK ILO W PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS
DRAINS-FLOOR.BOOR AREA. RECEIPIN
❑ WORKMAN COMPENDECLARATION SCHOOLTAX Y
N
rk
yualhavna cntteofemrentmaelf-insure,oracertiFoomof RECF1lTN
inn'Compemationncm.aoifedopmermf(Sm.38FIXTURiS-PER TRAP
covert 0lemployee's under this permit/ --- PARK FEE Y N
GAS-EA.SYSTEM-11NC.4 OUTLETS REC N
PoBUILDING D IS10N FEES
Comcopanw,y
❑ CertiEed copy is hereby fumiabed. F GAS-EA.SYSTRM-OVER 4(EA) PLANCHEC
'
❑ Cenilied copy it fled with the city inspection division. GREASEJINDUST'RLWASTEINTERCHPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS O
COMPENSATION INSURANCE
Mossectionneed nmbemmpleted ifthepermit isherome hundred dollars(E100) SEWER-SANITARY-STORM F.A.2WFT. Y ,E �N
or less)
I certify that in the performance ofnhe work fmwbich this permit is issued,I shall WATER HPATER WNENT/ELECTR
not employ my partan in my mender art as in become subject to the Workers' PAID
Z Compensation Lowaaf California. Dae WATER SYSTEM(MEATING Dam
0 O Applicant
4NOTICE TO APPLICANT.If.after making this Cenificare of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
Z) become subject to the Workers Compensation provisions of the Labor Code,you must
04 > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING EEE
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that them is n construction lending agency for performance of ELECTRIC FEE
O the work for which this permit is issued(Sm.309].Civ.C.)
Lender's Name
U Lender's Address Q'T'Y. MECHANICAL PERMIT W?13 PLUMBING FEC
I certify Wt 1 have read this application and sure that the above information is
correct. l agree to comply with all city and county ordinances and supe laws relating to PERMIT ISSUANCE MECHANICAL FEE
y building construction,and hereby authadee repasemupivea ofthis city Incineration the CONSTRUCTIONTAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilnie d u,cosband x hie ayin my way accmeagainst said City AIR HANDLING UNIT(TO 10,000 CEM) �–
U42�1 Lot 10
in ca gquJ rtni
/ t AIR HANDLING UNIT(OVER 10,000CFM)
Prgrutu�pplran sfe aData EXHAUST HOOD(W/DUCIJ
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,030 BTU) 244, Date Receipt#
Will the applicant or future building occupant store or handle heamdom material
ea defined by the Cupertino Municipal Cole,Chapter 9.12,and ate Health and Safety IIEATING UNIT(OVER 100,000 BTU) T I
Code.Seed.25332p)?11 Y ❑No 17
VFMIIATTON FAN(SINGLE RPSID)_T6.'a'
Will air co mor and,as building by the mu Area Air ualityc Mamaghemir
BOILER-COMP(JHP OR 100,W3 BTU) ISSUANCE DATE
vdom air conuminams v defined by the Bey Area Air Quality Management BOILER-COMP(OVER Ifib"BTU) P A B D
Gini
❑Yes ❑No NEW RESIDENTIAL MUCH.—SQ,FT.
1 have read the hamrdlaxaminu all requirements under Chapter 6.95 of the MAY m 4 94
Calif rim,Heahh @ Safety Code,Smile.25505.25533 and 25530.I understvM dun 1199
if the building does not currently have a tenant,that it is my respomibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate CIIY of V i r
Occupancy. Cn11 _
Owner or mahmioed ,at Dat T ISSUED Is .
OFFICE
W
Y,
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07
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No. 918
NJ�
Tit# Df Tupprtina
34pliartmPtit of "Nitilbinghoppriian
This certificate issued pursuant to the requirements- of Section 307 of the
f issuance this
Uniform Building Code certifying that at the time o
structure Yo7s
in compliance with the various ordinances of the city regulating building
construction or use. For the following:
Use Classification SERVICE STATION/CAR WASH/ FOOD MART — Bidg. Permi(No. 25776
Group - B1ZB2 '1Type Construction II-N
Use Zone 12LANNPD DFVPLQPMFNT
Ownerol'Building CHEVRON TJSA Address I 10 10 DR AN7A BT ql
Building Address 11010 DE, ANZE TATD — Locality -QUERTINO. CALIFORNIA
By: JOE ANTONnQCj Q` jyJ
a
Date: SEPTEMBER 2 , 1994
Building Official
POST INA CONSPICUOUS rLAcr
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No. 918
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, zy Tit of ii
� C�Iu#rertinn _
• ` = - �e.�1Mr#mets# of �ict��ing �n$.�er#inn. _; ;.�
v This certificate issued pursuant to the requirements of Section 307 of the
Uniform Building Code certifying that at the time of issuance this structure �ws
i F in compliance with the various ordinances of the city regulating building / 3
f construction or use. For the following: ;t
` UseClassirication _SERVICE STATION/CAR WASH/ FOOD MART Bldg. NrmitNo. 25776
t Group B1/B2 lypeConswction II—N - -
Use Zone PT.ANNED DF.VEi OPMFNm /
Ownerof Building CHEVRON tTSA Address 1 1 01 0 DF A7A R VD qt
Building Address __1 1 01 0 DF AN7A RT VD Locality CTTPFRTTNO, CALTFQRMTA
' By: — JOE ANTONWICI
Date: SEPTEMBER 2 , 1994-
Building
9d'Building Official 'n '
:l
AS
R; POST IN A CONSPICUOUS PUC[ -
TIE
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